Reluctance to release survey results uncovered

Emails about a 2017 endoscopy service survey in which some Southern District Health Board doctors claimed patients had been harmed reveal the service manager’s dissatisfaction with the recent damning independent review. Elspeth McLean reports.

Concerns the damning report that looked into concerns about Southland Hospital surgeons' access to colonoscopy was emotive, subjective and lacking in natural justice were raised by service manager for the Southern District Health Board's department of gastroenterology, Simon Donlevy.

In 12½ pages of feedback on the draft report from auditors Christchurch clinicians Phil Bagshaw and Steven Ding, Mr Donlevy, who is also service manager for the department of medicine in Southland, said auditors had not followed the terms of reference (TOR) for the review.

The reviewers have said the terms of reference were never finally agreed to.

The Bagshaw-Ding report called for an urgent overhaul of the management of colorectal cancer (CRC) in the Southern DHB area, drawing attention to the high incidence of CRC, the high rate of it having spread beyond the bowel at the time of initial diagnosis, the second-highest rate of emergency surgery for the disease in the country and one of the lowest colonoscopy rates. It also highlighted concerns about cultural and interpersonal relationships within the service and with other services.

Mr Donlevy said the report was subjective rather than systematic.

It did not identify the explicit criteria against which the 20 cases were reviewed (in which it was found that 10 had undue delay to diagnosis or treatment).

He criticised what he said was the focus on an "anonymised but easily recognisable member of the department" rather than looking at clinical changes that could be implemented to benefit patients and the gastroenterology department.

Mr Donlevy said the TOR acknowledged the disharmony that needed to be resolved between the Southland surgeons and the gastroenterology department, but this was not the reason for the audit.

"Nor does it seem fair, in terms of natural justice, to accept the views of some interviewees as to who is to `blame' for the poor relationships."

That would be the domain of a proper HR investigation and outside the remit of a clinical audit.

Concerns about natural justice were also raised by the clinical director of the service, Jason Hill, in an observations report in the appendices to the Bagshaw-Ding report, reported on in early July.

Mr Bagshaw has previously declined to comment on Dr Hill's report and, when asked about Mr Donlevy's feedback, he said he had read it.

Mr Donlevy's feedback was included in a response to an Official Information Act request about a 2017 online survey of users of the endoscopy service.*

Fifteen of the 82 respondents to the SurveyMonkey survey, conducted as a service improvement exercise, said they were aware of patients harmed as a direct result of a procedure not accepted when all relevant information was supplied.

Other concerns included under-resourcing, the rigidity of colonoscopy access and offensive or difficult communication with the service. Few of the 42 who gave general comments praised the service.

Questioned earlier this year about when the board's senior management was made aware of the survey results, board chief executive Chris Fleming said it did not appear the survey was escalated at the time, although concerns had been raised through other channels.

Regarding the non-escalation, Mr Fleming said it was not a matter of policy or procedure but basic professionalism would "expect it to be done". He suspected not doing it in this instance "comes back to culture".

The email trail released under the Official Information Act shows Mr Donlevy had asked chief medical officer Nigel Millar to review the survey before it went out, and this had been done.

However, nothing has been released showing that the results were conveyed to Dr Millar in 2017.

Once the results were in, they were discussed at a meeting of gastroenterology senior doctors. The minutes show proposed actions included improving wording of letters and forms and moves to lessen variation in practice when referrers had spoken directly to gastroenterologists.

During his audit interviews, Mr Bagshaw found out about the survey and sought a copy of it in early January.

By the end of January, when he said he was writing up his report, Mr Bagshaw emailed again, pointing out he still did not have the report, which had been sought again on January 16.

DHB surgical services and radiology general manager Dr Janine Cochrane emailed Mr Donlevy and Dr Hill on February 1 saying she had spoken with them both about this already.

She suggested a summary could be provided.

"Anyone can probably request it as an OIA (not going to suggest that one) but wondering if we can share."

If not, she asked for them to "provide words around why not".

Mr Donlevy replied the same day saying he did not want to be defensive or obstructive or "be a prick with regard to this" but he had concerns about correct process.

He did not consider the survey was within the scope of the audit and it was confidential.

He could not see how opinions expressed by anonymised individuals in 2017 could help form a view on the appropriateness or otherwise of the cases surgeons in Southland had raised as needing review.

The views of those already interviewed would also be expressed in the survey and so use of this information would create a bias.

He expressed the perception there had been "significant deviance from the TOR", which had left him feeling "exposed/vulnerable".

On the morning of February 7, Dr Cochrane emailed Mr Fleming pointing out Mr Donlevy and Dr Hill had raised issues about the report being outside the scope of the review. She forwarded the points made by Mr Donlevy.

She said she thought their points were well made.

"I have pointed out that it looks defensive and a bit obstructive," she said . However, Mr Donlevy had made some good observations.

Dr Cochrane suggested they tell Mr Bagshaw they would not provide the information because it did not specifically relate to the issues between gastroenterology and the surgical service at Southland Hospital, and the board encouraged services to seek feedback and did not wish this type of work to be examined outside the context of what was intended.

Mr Fleming (later that day): Is there any issue sharing it?

Dr Cochrane then asks Mr Donlevy, is there something in the summary report that was shared at the time "that we wouldn't want to share? I think this is the question".

Mr Donlevy: The only issue is how it will be used.

Dr Cochrane asks if she and Mr Fleming may have a look at the survey to assess this. Mr Donlevy sends the survey results to her and asks that he and Dr Hill have the opportunity to discuss "your thinking once you have assessed and before any action is taken".

No record of what happened after that has been released. Mr Bagshaw, impatient with the process, sourced the survey results from elsewhere.

Mr Fleming has not answered questions on how any decision, if there was one, was conveyed to Mr Bagshaw and, if this request could have been regarded as one for official information under the Act, why is there not a record of the decision on it.

*Two emails were withheld "to maintain the effective conduct of public affairs through the free and frank expression of opinions".

When this decision was questioned, the SDHB said the emails did not relate to the survey itself but "rather discussions about relationship issues that were discussed as a consequence of people participating in the survey. Addressing this is a live issue, involving external support. Releasing this information may be likely to prejudice the free and frank exchange of opinions in the course of dealing with this issue, and this would prejudice the effective conduct of public affairs".

Public interest in these emails did not outweigh the need to withhold them at this time. No indication of who they were to or from or when they occurred was given.

Further requests to the SDHB to consider this further were unsuccessful.

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